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Tuesday, 4 March 2014

The New Public Health System at Nearly One

With the public health system changes in England approaching their first anniversary it’s a good time to take stock and reflect. Much remains to be done as new relationships are forged and structures bed down but already some matters are becoming clearer. They pose a mix of threats and opportunities.

The new English public health system has nearly reached its first birthday

It’s in the nature of local government that some local authorities will rise to the challenge presented by public health more readily than others. But to assume that Whitehall, in the shape of the Department of Health or Public Health England, can step in and sort things out is both simplistic and naïve.

As a new report from the Institute for Public Policy Research on the relational state concludes, complex problems defy solution by central government and require all stakeholders, notably local government, to work in new ways to reshape public services. A reliance on bureaucratic and market-based tools is no longer ‘fit for purpose’ if it ever was.

So what are some of the key issues with which the new system is grappling and which will set the future direction in the run-up to the general election in May 2015 and beyond? I briefly explore four here.

Place-based budgeting

The prize in having public health return to local government is the opportunity afforded to adopt a place-based approach to harnessing resources to improve population health across whole communities and neighbourhoods.

Forget the ring-fenced public health budget. This is an often unhelpful distraction and is certainly likely to be time-limited. The real agenda is about pooling local resources from a range of bodies and determining how best to allocate them to meet identified needs.

Already community budgets are being developed in some local areas and there is scope to take this approach much further perhaps picking up from where the Total Place Pilots left off under the last government in 2010.

Role of Health and Wellbeing Boards (HWBs) and managing unrealistic expectations

A paradox of the public health changes is that Health and Wellbeing Boards (HWBs) have acquired huge prominence and expectations are high. They are seen as the system leaders locally charged with the task of promoting integrated health and social care, public health and overseeing the reconfiguration of health services in local areas. Yet they have virtually no powers.

These are significant and complex responsibilities and there must be doubts about HWBs’ abilities to deliver what is needed across all of them. The risk otherwise is that HWBs are being set up to fail. The wiser HWBs will not allow themselves to be stretched beyond their limits and will identify their key priorities and stick to them. Nevertheless, the temptation to take on responsibility for the entire health system will be hard to resist.

Role of Public Health England (PHE)

The new kid on the block is Public Health England and considerable uncertainty surrounds its place in the new architecture, both nationally and locally. Concerns exist over its independence from the Department of Health and this has yet to be thoroughly tested although the omens are not promising.

On minimum unit pricing for alcohol, PHE rested its case on the evidence which ultimately the government chose to ignore. And this is the problem – the evidence rarely speaks for itself. But for a body whose existence is predicated on presenting the evidence what options are open to it should those to whom it reports choose to ignore its advice? ‘Speaking truth to power’ is much more complex and political than simply marshalling and presenting the evidence in the hope that good sense will prevail.

In a new report on PHE, the House of Commons Health Committee is critical of what it sees as an ‘insufficient separation between PHE and the Department of Health’. It concludes that although PHE was created ‘to provide a fearless and independent national voice for public health in England’ it does not believe that ‘this voice has yet been sufficiently clearly heard’.

Local authorities remain wary and puzzled by PHE and the new centres appearing in their midst. They instinctively feel they do not want a central presence overshadowing their work. Conceivably, PHE can offer valuable support and resources but building effective, high trust relationships is proving tricky. It also takes time which is at a premium.

With an election looming in just over a year’s time, PHE will be under growing pressure to prove itself and demonstrate impact. Few cherish ‘quangos’ or arm’s length bodies, especially new ones.

Changing nature of workforce in terms of skills and capacities

Perhaps the most threatening challenge to the public health system, or possibly the one that offers most hope for real progress depending on where you sit in the new landscape, is the public health workforce and the changes which beckon. The issue divides opinion sharply and is intensely political since it confronts long-standing and fiercely held professional views.

There is no doubting that many moving into local government from the NHS are struggling to find their place in the new system. For the most part this comes down to a lack of understanding or appreciation of local government and its political dimension.

The leaders in local government are not the officers but the elected members. Many bring to public health issues considerable extant knowledge and experience of their communities and while this may not represent evidence in the conventional sense, it remains a key factor in decision-making.

I predict that the public health workforce in a few years’ time will look and feel very different. There will be casualties and not all local authorities will get it right but if local government is to serve public health better than the NHS, with exceptions, managed to do, then it’s time for a change in the workforce and its skills base.

The new public health leaders need to be politically astute, able to communicate well with different audiences, form relationships that enable things to get done, and assemble the business case for investing and disinvesting in public health. There are some Directors of Public Health who get it but many still don’t or have no wish to. They live in hope that what has happened to them will, like the floods affecting large parts of England, magically disappear so that life can return to normal.

Looking ahead, the challenges facing public health are hugely complex and require careful assessment and reflection as they unfold. None offers easy answers. While there are risks that the system will be unable to cope and fail to deliver, there is also renewed hope that what is being put in place offers an opportunity to promote health and wellbeing in a way that was only rhetorically advanced prior to April 2013.

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